Childbearing Exam #2 Study Guide

• Nursing Management o Priority o If HR more than 100 (red flag) hemorrhaging? o If Temp 100.4 24 hours after delivery maybe infection? o If Low BP signs ..maybe hemorrhage o If a lot of lochia check fundus FIRST could be boggy; If boggy massage it). If still boggy= (could be bladder) Ask patient to use bathroom; if still boggy could be neutrogenic bladder –Tell Dr. Right away (full bladder will displace uterus, full bladder will make it feel boggy) o If clot bigger than a dime could be hemorrhage o Electrolytes to check after giving birth – Chloride and sodium ▪ Actions • Postpartum bleeding – all women who give birth are at risk for excessive bleeding that can progress to postpartum hemorrhage o Assess vital signs (hypotension and tachycardia = shock, hemorrhaging) o Most frequent cause = uterine atony (failure of the uterine muscle to contract firmly) ▪ Maintain uterine tone ▪ Prevent bladder distension • Full bladder causes the uterus to be displaced – prevents normal contraction that is necessary after birth ▪ Medications • Oxytocin (Pitocin), misoprostol (Cytotec), Methergine, Meth prostaglandin o Other causes: overdistended uterus, general anesthesia, prolonged labor, history of uterine atony, retained placental fragments, trauma during labor or birth, unrepaired lacerations, ruptured uterus, placenta accreta – previa – abruption, coagulation disorders, hypertension o Involution: uterus returns to pre-pregnancy state: should not feel fundus after two weeks o Subinvolution: uterus is not shrinking • Lochia findings: notice color and amount/ weight perineal pads before and after use. o Alba: 10 and more “normal” discharge – lighter, whiter, creamy o A perineal pad that is soaked in 15 minutes or less or pooling of blood under the buttocks are indications of excessive blood loss and require immediate assessment and intervention o Color and amount should gradually lighten and decrease in amount, NOT return to a previous state o NO bright red blood – indicates active and continuous bleeding o Lochia finding should always improve and never go back to previous color or stage o Endometritis- heavy foul smelling lochia o How many times have you changed your pad ? o Average 6 peripads/ day NORMAL ▪ Assessment findings that require follow-up • Placental complications (placenta accreta): an abnormally implanted, invasive, or adhered placenta o Hysterectomy can be indicated, depending on how deep the placenta is implanted o Causes abnormal postpartum bleeding • Laceration or episiotomy o Prevent infection • MASSAGE THE FUNDUS; only if boggy • Assess Blood pressure when giving these meds sign, cool – pale – clammy skin, decreased urinary output, lethargy, anxiety If suspected, GET HELP. Start IV. Ensure airway. o S/S of hemorrhagic shock: rapid and shallow respirations, rapid and weak pulse, low BP is a LATE Up to 4-10 days o Serosa: lighter brown/pink 3-4 days o Rubra: deep, red/brown o Maintain a level of comfort o Avoid constipation (fiber, stool softner, fluids) o Perineal care – topical lidocaine cream; ice pack (vasocontraction (helps with swelling and pain), witch hazel, ice packs, peri bottle (cold water); sitz bath connected to cath and basin. Unclamp fluid is sprayed on perineum • Hematomas- localized collection of blood into tissues of reproductive sac o Pain is the most common symptom o Risk factors- use of epidural, prolonged 2nd stage labor, forceps for delivery o Provide pain relief, monitor for any abnormal bleeding, replace fluids, monitor labs (H&H) o Teaching: need antibiotic, help with house keeping, nurse baby on side, no iontercourse til stiches heal • Thrombophlebitis and thrombosis o Promote early ambulation • Uterine inversion o Occurs when fundus collapses into the uterine cavity (turns inside out) o Primary symptoms include hemorrhage, shock and pain • Mastitis o Flu-like symptoms o Localized breast pain and tenderness – hot and reddened area o Risk factors: inadequate emptying of breasts, sore – cracked, bleeding nipples, not washing hands o Tx: bed rest, antibiotics, reduce pain and swelling, continued lactation o Teaching: continue breast feeding, or pumping; empty breasts; use antibiotics; ice pack, analgesics • Engorgement o Breasts become “too full” o Breasts can become firm, tender and hot – can appear shiny or taut o If milk is not removed, breast milk production may reduce o If breastfeeding, feed or pump regularly (you can store it, save it, donate it), and apply warm water; storage o If NOT breastfeeding, 1st pump milk out then; do not touch breasts, apply cold water or cabbage leaves, wear a tight form-fitting bra; keep husband off breast (3-4 days) • Psychosocial complications o Postpartum blues (“baby blues”) ▪ Considered normal (due to fluctuating and changing hormones) ▪ Treatment is not necessary ▪ Symptoms should subside in less than two weeks o Postpartum depression ▪ Onset generally occurs in first few months after giving birth ▪ Intense and pervasive sadness with labile mood swings ▪ More persistent and serious than the baby blues – lasting more than 2 weeks ▪ Treatment is similar to “regular” depression o Postpartum psychosis ▪ Can be related to previous depression and bipolar diagnoses ▪ Most often occurs 2-4 weeks after birth ▪ Can lead to suicide or infanticide ▪ NEEDS TO BE TREATED AND RECOGNIZED ▪ Abnormal BUBBLE-HE assessment findings – questions to ask, priority actions • Breasts o Assessment includes nipples, breast tissue, temperature and color o Redness? Hardening? Swelling? o Teaching about Engorgement- • Uterus – fundal height ▪ 1st hours uterus is 1cm above umbilicus ▪ By day 10 fundus not palpable o Fundal assessment= 1st encourage mom to void, then massage fundus o Fundal assessment – lie flat with knees flexed o Involution NEEDS to occur – pre-pregnancy uterine state by 2 weeks after birth o Tone = needs to be firm ▪ Boggy = spongy ▪ Massage the fundus ▪ Full bladder can prevent fundus from remaining firm o If deviated, is the bladder full? ▪ Always have mom urinate before the assessment ▪ 1st 24 hours uterine atony – boggy fundus ▪ After 24- placenta fragments - placenta fragments still in uterus can cause boggy fundus • Bladder and bowel o “COLA” assessment ▪ Color, odor, last void/BM, amount ▪ Bowel movement is not “necessary” before discharge ▪ Must hear flatulence/ passing gas before advancing diet o Neurogenic bladder= loose ability to feel when to got to bathroom= Call HCP (order catheter) • Lochia o Rubra: deep, red/brown ▪ 3-4 days o Serosa: lighter brown/pink ▪ Up to 4-10 days o Alba: 10 and more “normal” discharge – lighter, whiter, creamy o A perineal pad that is soaked in 15 minutes or less or pooling of blood under the buttocks are indications of excessive blood loss and require immediate assessment and intervention o Color and amount should gradually lighten and decrease in amount, NOT return to a previous state o Clots – normal, but should be smaller than a dime o NO bright red blood – indicates active and continuous bleeding o Lochia finding should always improve and never go back to previous color or stage o How many times have you changed you pad? o Lochia amount: ▪ scant 1inch; Light (4 inches); ▪ Moderate (6 inches) dime size clot are normal ▪ Severe: bigger than dime clots.. bad hemorrhage ▪ PRIORITY ASSESSMENT: assess for boggy fundus can cause hemoraging • Episiotomy or incision o Monitor “REEDA” o Redness, edema, ecchymosis, discharge, approximation o Proper hygiene: topical medications, ice packs, Sitz baths, Peri-bottle o Infection: white/ silver line down abd o Endometritis- heavy foul smelling lochia o Perniuem assessment – hematoma, open laceration; dehiscence, evisceration; • Hemorrhoids o Prevent constipation- fiber, stool softener and fluids o SIMS- best view of hemorrhoids (one with leg up) o Check before advancing diet = check bowel sounds o Signs infection- painful, bleeding (bright red), itchy, cant sit= use • Emotional status o Monitor for signs and symptoms of depression (2 weeks) o Teach mom and family the difference between baby blues (normal 3-4 days), depression (needs meds) and psychosis (needs meds) (and how to monitor for each) o Normal versus abnormal feelings after birth NON – Bubble he assessment Vital signs - o Nursing assessment/interventions ▪ Interpreting values • Labs o H&H is critical to monitor ▪ They will decrease slightly during the first 24 hours after birth ▪ Should return to normal after 4-8 weeks o WBC will increase ▪ Return to normal after 1-2 weeks o Clotting factors and fibrinogen are normally increased o Platelets= 150,000- 450,000 • Education • Vital signs o Temp: can increase up to 100.4, should return to normal within 24 hours o Pulse: can remain elevated directly after birth, return to normal within 48 hours o Respirations: if increased during birth, should return to normal quickly o BP: Minimal increase should occur, any hypotension can be a late sign of hemorrhage o Remember signs of Hemorrhagic shock- tachycardia, hypotension ▪ What indicates a nursing intervention to manage a postpartum condition was effective? ▪ Recognizing high-risk patients • Any possible postpartum complication o Pre eclapsmia o Diabetes • Any type of incision • Possibility for bleeding? ▪ Facilitating bonding • Skin-to-skin contact ASAP – for at least an hour directly after birth • Have mom engage in ALL of the care of their child • Help mom take baby a bath • Maladaptive behavior bad- avoiding caring for patient o Lets baby cry, and stays on phone; ▪ Therapeutic communication • Culturally appropriate care following delivery o Not every mother follows the same “routine” following labor and birth (recognize and remember that!) o Circumcision for Jewish newborn o Asian patient/ diet /pain/ ▪ Does not emphasize touch ▪ Delayed breastfeeding ▪ Pain management ▪ Look at chart 1st; then ask patient o Appropriate teaching/responses for managing postpartum discomforts ▪ Breastfeeding difficulties • Pain and improper latching o Latch on: mouth over nipple, areola and breast ▪ Make a complete seal o If a baby does not latch properly, dry–cracked nipples (can become mastitis) • Painful, swollen breasts o Managing conditions in the postpartum period ▪ Diabetes mellitus I • Lower glucose levels in the immediate postpartum period • Many diabetic mothers will require much less insulin for several days after birth, especially if they are breastfeeding o Knowing if teaching is effective or ineffective ▪ Breastfeeding (best practices and managing complications) 1-6 months ▪ Benefits- less sick, economical, • Breastfeeding mom-additional 500 calories • Ideal time to initiate breastfeeding is within 1-2 hours after birth • Breastfeeding aids in contracting the uterus and preventing maternal hemorrhage o (Prolactin and Oxytocin) – baby sucking stimulates these hormones • Feed in any position that is comfortable for both mom and baby • How to know feeding is successful? o Mother reports firm tugging, no pinching or pain o Baby sucks with rounded cheeks, NOT dimpled o Baby’s jaw glides smoothly o Swallowing is usually audible